Provider Demographics
NPI:1821290446
Name:PADALECKI, JEFFREY RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RYAN
Last Name:PADALECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-406-7330
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54060207X00000X
TXN3968207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303081901Medicaid
TX303081902Medicaid
TX54060OtherTRAINING PERMIT
TX303081901Medicaid
TXTXB158423Medicare PIN
TX303081902Medicaid